Using the 5 A’s to help women quit

Using the 5 A’s to help women quit
Young Women & Tobacco Using the 5 A’s to help women quit

Acknowledgements This training was developed by the North Carolina Preconception Health Campaign, a program of the North Carolina Chapter of the March of Dimes, under a contract and in collaboration with the North Carolina Division of Public Health, Women’s Health Branch. This material was developed through support provided by the Department of Health and Human Services, Office of the Assistant Secretary for Health, Office of Adolescent Health (grant #SP1AH000004).

Acknowledgements Many thanks to these agencies and individuals for their generosity in sharing their resources in the area of tobacco cessation for women: The American College of Obstetrics and Gynecology The North Carolina Health and Wellness Trust Fund The UNC Center for Maternal & Infant Health Judy Ruffin, Women’s Health Branch, NC Division of Public Health Tish Singletary, Director of Training, NC Health & Wellness Trust Fund Specific resources used to guide the development of this training: Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit. You Quit Two Quit. Smoking Cessation: An Essential Maternal Child Health Intervention. ACOG Practice Bulletin, December 2009. The National Preconception Curriculum and Resources Guide for Clinicians (Module 1: Preconception Care: What it is and what it isn’t).

Young Moms Connect Brings together community partners to address challenges faced by pregnant or parenting teens using collaborative, multi-faceted strategies One component of Young Moms Connect is training for health care providers on six maternal and child health best practices Have local coordinator say a few words about the project in the local county at this point, if available.

MCH Best Practices Early entry and effective utilization of prenatal care Establishment and utilization of a medical home (for non-pregnant women) Reproductive life planning Tobacco cessation counseling using the 5 A’s approach Promotion of healthy weight Domestic violence prevention We’ll talk about this one today.

Objectives Increase provider understanding about how smoking cessation relates to opportunistic preconception health counseling Increase provider awareness about trends in smoking before, during and after pregnancy (also by county) and the influencing role of the health care provider Increase provider awareness about the need for tobacco cessation in high need populations to improve birth outcomes

Objectives (continued)
Improve provider counseling using the 5 A’s approach with all young women of childbearing age (and how this can be adapted for pregnant women who are ready and those who are not) Improve service delivery to extend provider practice standards for smoking cessation counseling services to 12 months postpartum Improve service delivery to address postpartum “relapse”

Objectives (continued)
Increase provider awareness of reimbursement options for tobacco cessation counseling and pharmacotherapy options Increase provider awareness of resources for patients and providers for smoking cessation

What is preconception care?
Identification of modifiable and non-modifiable risk factors for poor health and poor pregnancy outcomes before conception Timely counseling about risks and strategies to reduce the potential impact of the risks Risk reduction strategies consistent with best practices Preconception refers to a woman’s health status and risks before a first pregnancy or shortly before any pregnancy CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1)

Components of preconception care
Giving protection (i.e.: folic acid, immunizations) Managing conditions (i.e.: diabetes, maternal PKU, obesity, hypertension, hypothyroidism, STIs) Avoiding exposures known to be teratogenic (i.e.: medications, alcohol, tobacco, illicit drugs) Today we will be discussing how to help women prevent a poor birth outcome by avoiding their fetus’s exposure to tobacco. Definition of Teratogenic: Anything that is able to disturb, interrupt or compromise the growth of the fetus CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1)

“Opportunistic” care Preconception care is for every woman of childbearing potential every time she is seen Every woman, every time This is not necessarily doing more; it’s reframing the things you already do every day with the long-term lens of healthy women for healthy pregnancies for healthy birth outcomes and healthy women. Opportunistic care: provide counseling at every visit (sick, wellness, chronic condition, pediatric visit, prenatal, post-partum etc.) CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1)

Every woman, every time Young women who are at risk of pregnancy
Young women who are pregnant Young mothers who are postpartum Young mothers who are between pregnancies

Preconception health: Tobacco cessation
Smoking during pregnancy is the most modifiable risk factor for poor birth outcomes For women who may become pregnant and who smoke, provide opportunistic care about tobacco cessation For women who are pregnant, use prenatal visits to reduce/eliminate tobacco use For post-partum women, use the post-partum period to re-assess and assist women with tobacco cessation ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking Self Instructional Guide and Toolkit. An Educational Program from the American College of Obstetricians and Gynecologists (ACOG). ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011.

Maternal smoking during pregnancy
Increased risk for mother of: Preterm birth Ectopic pregnancy Placental complications Spontaneous abortion Stillbirth Serious implications for the mother of smoking during pregnancy… Smoking is causally associated with fetal growth restriction, and increasing evidence also suggests that smoking may cause stillbirth, preterm birth, placental abruption, and possibly also sudden infant death syndrome. Smoking during pregnancy also is generally associated with increased risks of spontaneous abortions, ectopic pregnancies, and placenta previa and may increase risks of behavioral disorders in childhood. Additional reference: Women and smoking: A report of the Surgeon General. Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General; Washington, DC, 2001. Cnattingius S. The epidemiology of smoking during pregnancy: Smoking prevalence, maternal characteristics, and pregnancy outcomes Nicotine Tob Res (2004)

Maternal smoking during pregnancy
Increased risk for child of: Low birth weight (causal association – twice as likely in smokers)1 Sudden Infant Death Syndrome1 Childhood respiratory illnesses2 Learning disabilities and conduct disorders1 If it were possible to eliminate smoking during pregnancy entirely, the infant mortality rate in North Carolina would drop 10-20%.3 We all are aware that smoking during and after pregnancy is associated with fetal and infant risks . Cigarette smoke doubles a woman’s risk of having a low birth weight baby, as well as increases the risk for pre-term birth and SIDS. Birth weight, SIDS, learning disabilities: Women and smoking: A report of the Surgeon General. Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General; Washington, DC, 2001. Respiratory illnesses: Hu FB, et al., Prevalence of asthma and wheezing in public schoolchildren: association with maternal smoking during pregnancy, Annals of Allergy, Asthma and Immunology 79(1): (July 1997) Tager IB, et al., "Maternal smoking during pregnancy: effects on lung function during the first 18 months of life, American Journal of Respiratory and Critical Care Medicine 152(3); (September 1995) IM drop of 10-20%: Rosenberg DC, Buescher PA. The Association of Maternal Smoking with Infant Mortality and Low Birth Weight in North Carolina, SCHS Studies No Raleigh, NC: North Carolina State Center for Health Statistics; 2002. 1Women and smoking: A report of the Surgeon General. U.S. Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General; Washington, DC, 2001. 2Hu FB, et al., Prevalence of asthma and wheezing in public schoolchildren: association with maternal smoking during pregnancy, Annals of Allergy, Asthma and Immunology 79(1): 3Rosenberg DC, Buescher PA. The Association of Maternal Smoking with Infant Mortality and Low Birth Weight in North Carolina, SCHS Studies No Raleigh, NC: North Carolina State Center for Health Statistics; 2002.

Infant Mortality, 2009 Rate per 1,000 live births Deaths 7.9 1,006
North Carolina 7.9 1,006 Onslow County 6.9 28 Nash County 10.2 4 Rockingham Co. 10.5 11 Bladen County 10.6 Wayne County 13.2 22 Dropping the IMR by up to 20% would translate into infant deaths prevented in your community. Keep in mind, the numbers for just one year are small. We need to look at trends over time to see true picture. Note that statewide rate for 5 year period of is 8.3 per 1,000 live births. Bladen: 4 deaths, rate: 29 for minorities, 0 for white Nash: 4 deaths, rate: 15.4 for minorities, 5.8 for white Onslow: 28 deaths, rate: 6.9, for minorities 13.9, 5.4 for white Rockingham, 11 deaths, 17.4 for minorities, 8.6 for white Wayne, 22 deaths, 22.4 for minorities, 7.7 for white NC State Center for Health Statistics, NC Infant Mortality Report , 2009, Table 1.

Low birth weight, 2004-2008 Percent of live births North Carolina 9.1
Onslow County 7.9 Wayne County 9.2 Rockingham County 9.7 Nash County 10.1 Bladen County 10.3 Remember – low birthweight is the birth outcome that is causally related with smoking during pregnancy. The rate is double in smokers vs. non-smokers is also statewide percent for 5-year period of See slide 15. NC State Center for Health Statistics, Trends in Key Health Indicators tables.

Smoking in North Carolina
20% of females ages define themselves as a current smoker Ages 25-34: 22% Ages 18-24: 19% 16% of females ages say they smoke every day Highest rates among women with low levels of educational attainment and/or high levels of poverty Young women and women with low education levels and/or high poverty have the highest rates of smoking, unintended pregnancy and birth rates, according to BRFSS. (Self-report) Source: 2009 NC Behavioral Risk Factor Surveillance System (NC BRFSS) NC Behavioral Risk Factor Surveillance System, 2009

NC female adolescent tobacco use
Female high school students who report using tobacco at least once in the last 30 days: 20% (any tobacco) 14% (cigarettes) 59% of female high school smokers report living with someone who smokes Sources: NC Youth Tobacco Survey, 2009 NC Dept. of Health and Human Services, Feb 2010 North Carolina Youth Tobacco Survey, 2009

Smoking during pregnancy
Nationally between 12-20% of all pregnant women report smoking during pregnancy Current clinical guidelines: “Whenever possible pregnant smokers should be offered person-to-person psychosocial interventions that exceed minimal advice to quit. Clinicians should offer effective tobacco dependence interventions to pregnant smokers at the first prenatal visit as well as throughout the course of pregnancy.” According to the National Partnership to Help Pregnant Smokers Quit: The "5 A's" Counseling Method An easy-to-implement, evidence-based clinical counseling approach, the "5 A's", can double or even triple quit rates among pregnant smokers. This approach has been published by the U. S. Public Health Service in its Treating Tobacco Use and Dependence Clinical Practice Guideline, and by the American College of Obstetricians and Gynecologists. The approach is effective for most pregnant smokers, including low-income women, the group most likely to smoke during pregnancy. Studies show that a brief counseling intervention of 5-15 minutes, when delivered by a trained health care professional and augmented with pregnancy-specific self-help materials, can double or, in some cases, triple smoking cessation rates among pregnant women. Martin JA et al. Births: Final data for National vital statistics reports. Vol 52 no 10. National Center for Health Statistics Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services

Smoking during pregnancy, 2005-2009
Number of women Percent North Carolina 70, 529 12 Bladen County 341 16 Nash County 759 Onslow County 1,821 11 Rockingham County 1,109 21 Wayne County 1,097 The % is based on live births – not pregnancies NC State Center for Health Statistics, NC Residents # and % of births to mothers that reported smoking prenatally

Smoking in the perinatal period
Time Period Percent of women reporting smoking Prior to pregnancy 22 During last 3 months of pregnancy 13 After pregnancy 18 Continuously (before, during & after) 12 *highest rates among younger women, less education and low income PRAMS 2008

Smoking after pregnancy
18% of women reported smoking after pregnancy in North Carolina Ages have the highest rates Of women who reported smoking before pregnancy, then quitting during pregnancy, roughly half began smoking again 3-6 months postpartum PRAMS 2008

Smokeless and non-cigarette tobacco use
Increasing prevalence among young women Pose serious health risks for the woman and her fetus Not a safer alternative to smoking Does not help smokers quit There is NO safe form of tobacco Some families have reported rubbing tobacco on their babies’ teething gums- this is not safe and not recommended. Source: Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit. An Educational Guide from the American College of Obstetricians and Gynecologists, Fiore, 2008 Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services

Smoking cessation during pregnancy: A maternal-child health best practice
Despite the well-known health risks associated with smoking during pregnancy, many women continue to smoke even after learning they are pregnant In a Cochrane review, successful smoking cessation during pregnancy resulted in a: 20% reduction in the number of low birthweight babies 17% decrease in preterm birth Lumley J, Oliver S, Water E. Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2000; CD

A teachable moment Women are more likely to quit at this time than any other time in their lives Generally motivated to have a healthy baby Brief counseling sessions are proven to work but are generally not integrated into regular prenatal care Cessation rates are 80% higher for women who receive counseling than for women who attempt quitting on their own Even pregnancy specific, self-help materials alone increase cessation rates (vs. usual care) Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services For further discussion, see also: ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011.

What providers can do Move beyond screening and recommendations
Provide brief smoking cessation counseling and use pregnancy-specific self-help materials Use the 5 A’s regularly with preconception, pregnant and post-partum patients Connect patients with support such as the NC Quitline 2008 Meta-analysis concludes that person-to-person psychosocial interventions are more effective than minimal advice to quit Also, helping with transition for new moms to a new medical home and smoking supports if they have passed the postpartum period and no longer qualify for Medicaid Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services

Quotes from new moms “I would have appreciated more help to stop smoking during my pregnancy. I don’t think doctors emphasize that enough.” “I think doctors should advise patients to quit more aggressively.” PRAMS survey participants, 2007

The 5 As Easy to implement Evidence-based Clinical counseling approach
Ask Advise Assess Assist Arrange Easy to implement Evidence-based Clinical counseling approach Effective for most pregnant smokers Also works preconceptionally and during the post-partum period This is an easy-to-implement, evidence-based clinical counseling approach, the "5 A's", can double or even triple quit rates among pregnant smokers. The PHS guideline approaches smoking as a chronic condition, similar to diabetes or hypertension, and stresses the need for regular, consistent counseling. This approach has been published by the U. S. Public Health Service in its Treating Tobacco Use and Dependence Clinical Practice Guideline, and by the American College of Obstetricians and Gynecologists. The approach is effective for most pregnant smokers, including low-income women, the group most likely to smoke during pregnancy. Its useful for young smokers and post-partum smokers as well. It follows a specific protocol or algorithm with some scripted material. The suggested language can be adapted to the clinician’s personal style and the patient’s individual needs. Note: The source for all the 5 A’s slides (29-49) is the ACOG CME module that is also included in the toolkits – participants are encouraged to read the entire booklet cover-to-cover as it is full of great information! ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011. Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services For further discussion, see also: ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011.

ASK: Patients who are pregnant
Advise Assess Assist Arrange Which of the following statements best describes your cigarette smoking? I have NEVER smoked, or have smoked LESS THAN 100 cigarettes in my lifetime. I stopped smoking BEFORE I found out I was pregnant, and I am not smoking now. I stopped smoking AFTER I found out I was pregnant, and I am not smoking now. I smoke some now, but I cut down on the number of cigarettes I smoke SINCE I found out I was pregnant. I smoke regularly now, about the same as BEFORE I found out I was pregnant. The recommendation is to systematically identify all tobacco users. 13-26% of pregnant smokers may not disclose that they smoke when asked about it as part of a routine clinical interview. With pregnant patients the stakes are high in terms of getting smoking patients to disclose. The social stigma is also high and this affects women’s reluctance to disclose. Studies have confirmed that asking pregnant women each time you see them using a multiple choice format is most effective. Ask participants for some examples that demonstrate ineffective ways to screen for smoking status? Do you smoke? Are you a smoker? Do you consider yourself to be a smoker? Are you addicted to cigarettes? Now ask participants for some examples to start the conversation that will increase the likelihood of disclosure. We ask all our patients each time we see them to answer some questions about smoking…. Please fill out this quick survey….. Which of the following best describes your cigarette smoking? Ask participants to split into pairs and practice asking a hypothetical pregnant patient about her smoking status. Walk through the room and give feedback to participants as you see them use the multiple choice script. A single yes/no question is not enough. Then after 3 minutes or so ask participants to switch roles and repeat the practice exercise.

ASK: Patients who are not pregnant
Advise Assess Assist Arrange Ask if she has ever smoked, or smoked fewer than 100 cigarettes in her lifetime Ask if she uses any of the following tobacco products: chewing or smokeless tobacco, little cigars or cigarillos, Hookah, snuff, melt in your mouth orbs, sticks or strips Ask if someone smokes inside her house, in her car, around her, or at her workplace For patients that have never been pregnant you can use a variation of the pregnant smoker’s script: see 3 questions on slide. Consider asking about her smoking status as one her vital signs Employ a universal identification system (ie: stickers, computer reminders) Keep in mind that adolescents can start smoking any time so its especially important to ask them at each visit. Adolescents can become addicted very quickly and are already established smokers by the time the have smoked 100 cigarettes. Ask participants to think of ways that they can think of ways to integrate the ASK question into everyday clinic routines? Record responses on a flip chart. Ensure the following are included: Program a reminder into the EMR system to screen for tobacco use Use the standardized multiple choice question to ask patients about smoking status Record smoking status as a vital sign in the patient record

ASK: Patients who are postpartum or between pregnancies
Advise Assess Assist Arrange Ask the patient to choose the statement that best describes her smoking status: I have NEVER smoked or have smoked less than 100 cigarettes in my life. I stopped smoking BEFORE I found out I was pregnant and am not smoking now. I stopped smoking AFTER I found out I was pregnant and I am not smoking now. I stopped smoking during pregnancy, but I am smoking now. I smoked during pregnancy and I am smoking now.

ASK Use a concerned, helpful tone when you ask about smoking
Advise Assess Assist Arrange Use a concerned, helpful tone when you ask about smoking Use a multiple choice format Use either a written survey or clinical interview Asking “Do you smoke” isn’t as effective as asking in a multiple choice format. Use a non-judgmental tone. Ask at multiple visits to your office.

ADVISE Strongly urge all tobacco users to quit Use clear language
Ask Advise Assess Assist Arrange Strongly urge all tobacco users to quit Use clear language Use a strong tone Use a personalized message This is the portion of the counseling session where you make your recommendation to her, you share important information and you answer her questions all as part of starting the conversation about quitting. For pregnant women, provide clear, strong advice to quit with personalized messages about the impact of smoking on mother and fetus. Examples: My best advice for you and your baby is for you to quit smoking. It is important for you to quit smoking now for your health and the health of your baby, and I can help you. As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your baby and your own health. The clinic staff and I can help you.

ADVISE: Link to motivational points
Ask Advise Assess Assist Arrange Tailor to her personal situation Use positive language Focus on positive benefits of quitting Use appropriate motivational messages Tailor your advise to the patient’s situation and their responses to the ASK portion. Use positive language and focus on the positive benefits of quitting. Its important to not make the patient feel criticized or shamed, instead let her that you are aware of how hard this is and that you want to be a support to her. Use Demonstration Activity: Advise-Negative/Positive (Found in Training Guide) Its common for patients to minimize the risks and dangers smoking poses to infants and the long-term health risks for mothers. If patients know people that have had uncomplicated, healthy pregnancies while smoking, focusing on bad outcomes such as low birth weight or delivery complications would be ineffective. Its important to find points that would motivate them personally to quit. Use Demonstration Activity: Advise Using Motivational Points (Found in Training Guide)

ADVISE: Acknowledge barriers
Ask Advise Assess Assist Arrange “I know I’m asking you to do something that takes a lot of effort, but my best advice to you (and your baby) is to quit smoking. I also see from your questionnaire that you have a history of bronchitis and asthma. Quitting smoking will help you feel better (and provide a healthier environment for your baby).” Acknowledging barriers to quitting while providing encouragement may make the patient more receptive to advice. Try to include a personal reason for quitting identified by the patient herself. Some examples to build from might include: she mentions that a family member developed lung cancer from smoking, a friend had a preterm baby and she smoked during pregnancy, she herself suffers from asthma, she herself can’t exercise comfortably because of feeling winded and coughing, etc. Use Demonstration Activity: Advise - Acknowledging Barriers (Found in Training Guide)

ADVISE: Recent quitters to remain smoke-free
Ask Advise Assess Assist Arrange Congratulate! Reiterate the importance of staying smoke free for her own health, any current or future pregnancies and any current or future children Let her know you will be asking about her smoking status in future visits

ASSESS Ask Advise Assess Assist Arrange Assess the willingness of the patient to make a quit attempt within the next 30 days For women who are ready, move on to ASSIST For women not ready to try quitting or commit to quitting, use the 5 R’s Depending on the next scheduled visit, or if she is pregnant- how far along the pregnancy is, make a decision together about setting a quit date within 30 days.

The 5 R’s Relevance Risks Rewards Roadblocks Repetition
It is unnecessary to address all the 5 Rs in a single visit. Consider 1 or 2 that are relevant depending on the patient’s comments in the ADVISE and ASSESS steps. Choose the appropriate R to first work on. For all these steps it is important for the woman to feel ownership of the process. Ask her with leading questions to identify the following: Relevance: What are the reasons to quit that are relevant to her situation? The point here is to identify what the motivational factors are for her and this will be different for each woman. For example, saving money, breathing easier during exercise which will help her lose weight, wanting a healthy baby, improving her odor and appearance to attract a new partner, etc. Risks: What are the risks or negative consequences of smoking for her, her baby, her children/family, etc.? This should be tailored to her stage of life. If she is pregnant, focus on the consequences for a developing fetus or baby. If the patient says that the last time she was pregnant she smoked and her baby was fine, you should spend more time here in “risks” and focus on education. Rewards: Here we ask the woman to imagine what life would be like for her and her loved ones if she quit smoking. Ask her to create a very specific list of reasons to quit- name names “If I quit smoking my 18 month old son might have less asthma and bronchitis infections.” Try to frame these in the “positive.” Roadblocks: We know a lot of smokers get caught up in the reasons why quitting hasn’t worked before, why it would be challenging now- the barriers. This is a time to problem-solve together and walk through some helpful patient materials and treatment options together. If her partner smokes and she sees this as a roadblock help her practice negotiating a smoke free zone for her home with her partner and identify a group of family and friends that will support her and help keep her busy when she is dealing with cravings. Repetition: Every time you see her ask about her smoking status and her readiness and willingness to quit. Plead your case each time and help her understand that every quit attempt brings her closer to quitting for good.

Relevance Patient should discuss why quitting would be personally relevant Help her identify motivational factors of her own Link the motivational factor to her personal situation Be specific For example, if she has children you would work with her to make a list of all the potential health risks to her children if she continues to smoke (ie: second and third hand smoke). You could also list the financial costs of her smoking and how that affects her ability to provide for her children. You might even list social stigma that the children face because of her smoking (their clothes smell like smoke, she leaves children’s events to smoke, other parents disapprove and this affects their friendships). And finally you might list her children’s psychological fears of her dying early. Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit. An Educational Guide from the American College of Obstetricians and Gynecologists.

Risks Ask her to list potential negative consequences of smoking
If patient is unaware of risks, this is a teachable moment- share information Tailor risks for where she is in life No pregnancies yet Pregnant Postpartum Between pregnancies Although you may not want to quit right now or are not ready to quit, please share what you have heard about …..(Choose one or more of the following to discuss with the patient, making it relevant to her current life situation.) Smoking and pregnancy Effects of smoking around babies and young children Efects of smoking when children live with you Long term effects on your own health and mortality Financial costs of smoking Of special note is some women think that if they have already had a healthy baby while smoking that the risks are overstated or don’t apply to her. Or, some women know other women who smoked during pregnancy and had healthy babies and this is their frame of reference when they talk about preconception health. For these women its important to explain that every pregnancy is different and that her body changes as well as she gets older. Smoking longer may have impact the development of a chronic disease that could impact a future pregnancy and delivery. The absence of complications in a previous pregnancy (or another woman’s pregnancy) does not guarantee future pregnancies free of problems.

Rewards Ask the patient to think about how quitting might benefit her and her family Give her examples tailored to her situation Use the patient’s history and comments about her smoking behavior to create a checklist of factors that will increase her motivation to quit For example, a pregnant woman’s checklist might include: Bringing the baby home from the hospital with her Baby being a healthy weight, born full term and having no breathing problems Less time at medical appointments Saving money Pleasing family and friends Healthier skin, smelling better Protecting a child with asthma or from asthma \

Roadblocks Ask the woman what she thinks her barriers to quitting are
Talk through problem solving strategies Demonstrate tools Refer back to the group brainstorm about Barriers and Coping Strategies.

Repetition At each subsequent appointment ask if she has changed her mind about trying to quit Explain that many people have to try more than once to quit and that each new attempt to quit increases the likelihood of quitting for good Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit. An Educational Guide from the American College of Obstetricians and Gynecologists.

ASSIST Set a quit date Use a direct approach
Ask Advise Assess Assist Arrange Set a quit date Use a direct approach Avoid dates of significant events such as a birthday or anniversary Use a Quit Contract or record the quit date in a patient education material You need to choose a quit date so that you can be prepared. Would it be easier to quit on a weekday or a weekend?

ASSIST Assess/arrange for support in the smoker’s environment
Ask Advise Assess Assist Arrange Assess/arrange for support in the smoker’s environment Provide pregnancy or post-partum specific, self-help smoking cessation materials & review with patient Help patient envision and have a plan for cravings, withdrawal symptoms and social situations Ask patient to prioritize 1 or 2 concerns or potential barriers Provide reinforcement through a congratulatory letter or phone call This is the “doing” part of the 5As. Help the patient identify people in her own environment who can help and encourage her to quit. The patient’s partner may not be the most likely choice o provide support. Ask her about others in her family and social circle who can provide encouragement and support (ie: distraction activities like talking on the phone, going for walks, etc.). Patient education materials that reinforce the counseling in the ASSIST step are helpful. For pregnant patients, pregnancy-specific materials have been found to improve quit rates compared to interventions without self help materials. Review some patient education tools from Section 4 of the Tool Kit, especially the Quitline information. Problem solving assistance can be spread over several visits and the coaches from the Quitline can also help with this. Patients may feel overwhelmed by a number of potential barriers to quitting. Helping her identify 1 or 2 areas to focus on and provide problem-solving techniques or materials to help address. Support both within the health care office and in the patient’s environment are important parts of the ASSIST step. Office staff who interact with patients should keep a positive attitude concerning smoking cessation to encourage and support ANY attempt to stop smoking.

ASSIST Make a referral to the NC Quitline: 1-800-QUITNOW
Ask Advise Assess Assist Arrange Make a referral to the NC Quitline: QUITNOW Trained cessation coaches have protocols for pregnant women and adolescents/young adults Patients can also text COACH to to receive cessation advice via their mobile phones Free, 8am-3am, 7 days a week Fax referral service speeds up the process The Quitline has proactive coaches who can initiate calls to patients who are ready to quit. See section 4 in binder: p. 5 of the North Carolina smoking cessation resources guide – here you’ll find specific information about how to refer to the Quitline. Or go to and click on “For medical professionals.” There is also a consumer section of the website.

Assisting heavy smokers
Pregnant women who smoke more than a pack a day and are unable to quit after the 5As and the 5Rs may need more help The NC Quitline is helpful for heavy smokers Intensive behavioral counseling may be necessary via referral

ARRANGE Make follow-up visits
Ask Advise Assess Assist Arrange Make follow-up visits Repeatedly assess smoking status and, if she is a continuing smoker, encourage cessation For patients trying to quit these visits should allow time to: Monitor progress Reinforce the steps toward quitting Promote problem solving skills to prevent relapse or quickly recover from relapse Patients who are still smoking should be encouraged to quit at every opportunity. If you are seeing the patient only through the postpartum period help her establish a medical home for herself to continue preconception and interconception care, including smoking cessation services. Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit. An Educational Guide from the American College of Obstetricians and Gynecologists.

Postpartum relapse 45%-70% of women who quit smoking during pregnancy relapse within 1 year of delivery Relapse may be delayed or avoided among women who receive smoking cessation counseling during the postpartum period For this reason it’s important to use the post-partum check up visit to assess smoking status and refer to a primary care provider as necessary, specifically to continue postpartum smoking assessments and intervention with the 5 A’s. US Department of Health and Human Services. Women and Smoking: A Report of the Surgeon General McBride CM et al. Prevention of relapse in women who quit smoking during pregnancy. Am J Public Health 1999;89:

Preventing postpartum relapse
Good documentation Use the 5 A’s at the postpartum visit Use positive language to counsel Reiterate messages of: Risks to babies and children from smoke exposure Make your home a SMOKE FREE ZONE Praise for efforts to quit and stay quit Keeping track of smoking status and smoking history with prompts to ASK at every interaction.

Treating postpartum relapse
Reassure and encourage her to try again Ask her to: Quit immediately and put it in writing Get rid of all smoking materials Talk about what worked initially and what may have led to the relapse Prioritize smoking cessation over post-partum weight loss

Treating postpartum relapse
Encouragement Review triggers Refer back to NC Quitline Refer back to self help materials Breastfeeding should always be encouraged If she is not breastfeeding, consider prescribing a pharmacologic aid Ensure that the patient has a medical home for follow up beyond the postpartum period We’ll discuss breastfeeding and pharmacologic aids in a moment… Nicotine replacement therapies pass into breast milk There is limited information available about the effects on infants of the use of buproprion and varenicline during lactation. See notes on slide 56 for more info on this point.

Activity Trainer: Choose appropriate activity from Trainer’s Guide to model or practice 5 A’s counseling in small groups

When the 5 A’s approach isn't enough
Referral for intensive counseling with a specialized provider Pharmacotherapy options* Nicotine replacement Gum, patches, lozenges, nasal spray and inhalers *Careful consideration; benefits must outweigh the risks *Many experts do not consider using these as an option during pregnancy The US Public Health Service Guidelines state that behavioral interventions should always be the first line of treatment for pregnant smokers. The use of pharmacotherapy during pregnancy, including over the counter nicotine replacement and prescription oral medications is controversial. Also, it is not clear that it is effective during pregnancy. The guideline also advises providers to carefully consider use of medications used to treat tobacco dependence (nicotine replacement and bupropion) for pregnant women because they have not been tested for safety and efficacy during pregnancy. Pharmacotherapies should be used only for pregnant women who smoke heavily and are unable to quit using counseling methods, and only when the potential benefits and likelihood of quitting are likely to outweigh the potential risks. Many experts do not advise using them at all during pregnancy. The FDA has placed a black-box warning on all antidepressants (Bupropion)and varenicline as their use increases the risk of suicide, particularly among adolescents and young adults. Clearly, this is not a good option for the target patient population that this training is addressing. ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011. You Quit Two Quit Practice Bulletin. Smoking Cessation: An Essential Maternal Child Health Intervention, 2009.

Pharmacotherapy and lactation
Nicotine replacement therapies pass into breast milk The highest dose (21 mg) = 17 cigarettes in breast milk 14 mg and 7 mg result in much lower amounts of nicotine passing into breast milk Gum and lozenges pass variable amounts depending on how much is chewed and frequency of use Buproprion may reduce milk supply There is limited information available about the effects on infants of the use of buproprion and varenicline during lactation. Please refer to the chart on page 6 of the Practice Bulletin, December You Quit Two Quit. Smoking Cessation: An Essential Maternal Child Health Intervention for more information. Found in your binder – section 3. Additional resources found at: Nicotens.LACTMED: Drug and Lactation Database. National Institutes of Health. Available from: Buproprion and Chantix. Medication and Mothers Milk Discussion Forum. Available from: ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011. You Quit Two Quit Practice Bulletin. Smoking Cessation: An Essential Maternal Child Health Intervention, 2009.

Pharmacotherapy for non-lactating postpartum women
Good option for those women for whom behavioral interventions have not been effective All forms of nicotine replacement increase the success of a quit attempt by 50%-70% Source: Practice Bulletin, December YouQuitTwoQuit. Smoking Cessation: An Essential Maternal Child Health Intervention. Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotene replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No. CD pub3. Stead LF et al. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No. CD pub3 You Quit Two Quit Practice Bulletin. Smoking Cessation: An Essential Maternal Child Health Intervention, 2009.

Reimbursement for smoking cessation counseling
Not one-size-fits-all: Each facility should investigate reimbursement options to maximize their payments for this important service Facilities such as a health department or a hospital generally use a facility rate Facilitate a conversation about how various providers and facilities are billing for smoking cessation services (to both Medicaid and private insurers).

Medicaid covers smoking cessation counseling
Smoking cessation counseling CPT codes: 99406 – Intermediate visit (3-10 minutes) 99407 – Intensive visit (> 10 minutes) An appropriate tobacco-related diagnosis, such as ICD-9 code (tobacco abuse), must be filed in addition to the Evaluation and Management code and submitted with the CPT code For more information, go to: As of January 1, 2009, physicians, nurse practitioners and health departments can receive reimbursement for the following Smoking Cessation Counseling CPT codes: 99406 – Intermediate visit (3-10 minutes) 99407 – Intensive visit (> 10 minutes) An appropriate tobacco-related diagnosis, such as ICD-9 code (tobacco abuse), must be filed in addition to the Evaluation and Management code and submitted with the CPT code. In addition to physicians, nurse practitioners, and health departments, these codes can be billed “incident to” the physician by the following professional specialties: licensed psychologists, licensed psychological associates, licensed clinical social workers, licensed professional counselors, licensed marriage and family counselors, certified nurse practitioners, certified clinical nurse specialists, licensed clinical addictions specialists or certified clinical supervisors. Practitioners must continue to follow the guidelines for services provided “incident to” the physician. Refer to the article tiled Modification in Supervision When Practicing “Incident To” a Physician in the October 2008 general Medicaid bulletin for additional information. For more information, please see the January 2009 NC Medicaid Bulletin: A copy of the relevant sections of this bulletin is found in your binder at the end of Section 3.

Creating a supportive health care facility environment
Implement a tobacco user identification system Dedicate specific staff to provide tobacco cessation treatment Educate and gain input from staff about implementing tobacco cessation services Assign one person to coordinate and monitor implementation Train staff on 5 A’s Adapt procedures to your specific setting Extend postpartum tobacco cessation services to 12 months post-partum Invite staff to participate in the planning process. Provide and overview of the 5As (not a training) at the beginning and emphasize that encouragement from staff members has been shown to help patients quit smoking. Use handout for small group work here – see module at a glance and training materials. Source: Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit. An Educational Guide from the American College of Obstetricians and Gynecologists. ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011.

Summary: 5 A’s Ask: Systematically identify all tobacco users
Advise Assess Assist Arrange Ask: Systematically identify all tobacco users Advise: Strongly urge all tobacco users to quit Assess: Determine willingness to quit Assist: Set a quit date, materials, problem solve Arrange: Make plans to monitor smoking status, provide reinforcement, support and encouragement The 5 As works best when: There is a tobacco user identification system in place Staff have all been educated and collectively are “on board” in terms of using encouraging, motivational tones with patients Staff have been assigned roles Patient materials and referral services are on hand

Summary Identify and counsel young women who use tobacco and are at risk for pregnancy The 5 A’s approach is an effective, evidence-based method of achieving smoking cessation during before, during and after pregnancy Maintaining cessation in the post-partum period is challenging and post-partum relapse is common Postpartum relapse can be prevented with proper postpartum screening, 5 A’s approach, and extended cessation services to 12 months postpartum

Using the 5 A’s to help women quit

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Using the 5 A’s to help women quit

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